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Y Ut5L1C tit:AL'1'tt SY;LtV1C:Y�.i -r.:>,v V1XU1VP1r lY '1'riL. IIrau=" Ulv1. JlUB <br /> SITE NAME Mot �� ADDRESS (`30 CITY tcck cz, � <br /> OWNER NAME CC-C Ulf ) I OWNER PHONE # <br /> CONTRACTOR �` SC}� CONT . PHONE # <br /> FIRE PERMIT <br /> REMOVAL ' CLOSURE IN PLACE TEMPORARY CLOSURE <br /> r <br /> CA <br /> INSPECTOR � , ,� i ,_; DATES TANK 1 39 / / SO ( <br /> � � � <br /> R RINSED N ) METHOD ' Q G _ RINSE AMOUNT <br /> I vv <br /> N RINSATE DISPOSAL SITE <br /> S AFi 'SOON <br /> E MANIFEST OR OTHER d <br /> V VAPORS PURGED /N ) METHOD > �� i ICS AMOUNT USED � } - <br /> A <br /> P READING AT REMOVAL L . E . L . : 02 : <br /> 0 <br /> R COMMENTS � <br /> C TANK MATERIAL TEEL FIBERGLASS , OTHER ) <br /> ( S <br /> 0 <br /> r - - <br /> N TANK CONDITION ( GOOD , OOR�, HOLES ) <br /> S <br /> T PIPE MATERIALTEEL % FIBERGLASS , OTHER ) 2 FEET w'C <br /> PIPE CONDITION ( GOOD , `POOJ. HOLES ) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE a <br /> T <br /> K 1 <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L . I <br /> I P - <br /> N � �� <br /> N E <br /> G <br /> Ll TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G . W . : FT . SAMPLING METHOD <br /> H <br /> 2 D4 HOURS SINCE DEWATERING : <br /> 0 <br /> OTHER SAMPLE : <br /> LABORATORY : SAMPLERS NAME : <br /> CLOSURE IN PLACE MIXTURE : VOLUME : <br /> EH 23 - 0043 (REV 2 / 23 / 94 ) PROVIDE SITE MAP <br />